Anabolic Bone Pharmacologic Treatment Recommendation
For this 80-year-old woman with severe osteoporosis, multiple non-vertebral fractures (pelvic and proximal humerus), and very high fracture risk, teriparatide is the optimal anabolic agent, followed by mandatory transition to an antiresorptive agent after completion of therapy. 1, 2
Rationale for Anabolic Therapy Selection
This patient meets criteria for very high fracture risk based on: age >74 years, multiple prior osteoporotic fractures (two pelvic, one proximal humerus), and the clinical presentation of severe osteoporosis. 2 These characteristics warrant first-line anabolic therapy rather than antiresorptive agents. 2
Why Teriparatide Over Romosozumab
Teriparatide is the preferred anabolic agent for the following reasons:
Superior non-vertebral fracture reduction: Teriparatide reduces vertebral fractures by 65-69% and non-vertebral fragility fractures by 45-53%, which directly addresses this patient's pattern of pelvic and proximal humerus fractures. 3, 4, 5
Romosozumab limitations: While romosozumab is FDA-approved for high-risk postmenopausal osteoporosis 6, it has only conditional recommendation status with low-certainty evidence 2, and cardiovascular safety concerns may be relevant in an 80-year-old patient. 7
Established efficacy in elderly patients: Teriparatide has robust evidence in postmenopausal women with multiple fractures and does not require dose adjustment for age. 3, 8
Treatment Protocol
Initial Phase: Teriparatide
- Dosing: 20 mcg subcutaneous injection daily for 18-24 months (maximum 2 years lifetime exposure). 1, 3, 8
- Mechanism: Stimulates new bone formation and restores bone architecture, with rapid increases in bone formation markers. 3, 4
- Expected outcomes: 10% increase in spine BMD, 3% increase in hip BMD, and significant fracture risk reduction. 3
Mandatory Transition Phase
Critical: After completing teriparatide therapy, the patient must transition to an antiresorptive agent (bisphosphonate or denosumab) to maintain bone gains and prevent rebound fractures. 1, 2, 4 The anabolic effect wanes after 12 months, and failure to transition risks losing all benefits. 6, 4
Essential Adjunctive Measures
All patients require:
- Calcium: 1,000-1,200 mg daily 1, 2
- Vitamin D: 800-1,000 IU daily 1, 2
- Fall prevention counseling: Critical given chronic severe back pain 2
- Weight-bearing and resistance exercises 2
Contraindications to Verify
Before prescribing teriparatide, confirm absence of:
- Paget's disease of bone (increased osteosarcoma risk) 9
- Prior skeletal radiation therapy 9
- Bone metastases or history of skeletal malignancies 9
- Active malignancies prone to bone metastases (breast, prostate, lung, kidney, thyroid) 9
Monitoring and Safety
- Hypercalcemia monitoring: Check calcium 4-6 hours post-injection initially, as mild transient hypercalcemia can occur. 5
- Urinary calcium: May increase by approximately 30 mg/day. 5
- Treatment compliance: Daily subcutaneous injections require patient education and adherence support. 8
- Well-tolerated profile: No serious adverse effects in clinical trials, with favorable compliance rates. 3, 8
Why Not Bisphosphonates First?
While bisphosphonates are first-line for most osteoporosis patients 10, this patient's very high fracture risk with multiple non-vertebral fractures places her in the category where anabolic agents should be initiated first, followed by antiresorptive therapy. 2 Bisphosphonates reduce vertebral fractures by 50-70% and non-vertebral by 20-30% 7, but teriparatide's 45-53% non-vertebral fracture reduction 4 and bone-building mechanism make it superior for this severe presentation.
Cost Considerations
Important caveat: Teriparatide is significantly more expensive than generic bisphosphonates. 1, 8 However, given the severity of this patient's presentation with multiple fractures and very high ongoing fracture risk, the superior efficacy justifies the cost. 8 After completing teriparatide, transition to generic bisphosphonates for cost-effective maintenance. 10, 1